Pre- and Postoperative Pain Management Lora McGuire, MS, RN
Disclosure Consultant/speaker’s bureau –Janssen Pharmaceuticals
Learning Objectives Explain the concept of preemptive analgesia Describe the use of non-opioid analgesics in the management of pre and postop pain Compare opioid analgesics for the management of post-op pain Discuss the routes of analgesic administration that can be used effectively to relieve pain
Patients have a right to the appropriate assessment and management of pain The Joint Commission, 2001
Clinical Definition of Pain Pain is whatever the person says it is and exists whenever he says it does McCaffery, 1968
Pain Number one reason a person seeks out a health professional Is an expected consequence of surgery In one-half of all surgeries pain is inadequately managed
Dunwoody, 2008
Acute vs Chronic Acute pain –Time-limited –Cause usually known –Diminishes with healing –May have observable signs and symptoms –Examples?
Acute Pain A significant clinical problem in US and postoperative pain remains under treated Wu & Raja, 2011
50% of postoperative patients have at least moderate pain and more than 1/3 report severe or extreme pain Apfelbaum et al, 2003
During the first postoperative week, readmissions related to pain exceed all others Coley, 2002
Acute Pain Can Lead to Chronic Pain If inadequately treated, acute pain can lead to chronic, persistent pain If pain persists, abnormal pain conditions such as hyperalgesia or allodynia may develop
Pasero, 2011
Pasero, 2011
An increased sensitivity to pain can cause “Wind-Up Syndrome” with more excitable neurons causing changes in CNS
Core Curriculum, 2010
Consequences of Unrelieved Pain Increased BP, HR Increased consumption of MI oxygen Increased metabolic rate Decreased gastric motility Stress response
Sleeplessness Altered pul. function Delayed healing Reduced mobility Reduced cognitive function Increased risk for chronic pain Pasero & McCaffery, 2011
In A Study Of Hospitalized Older Adults (Over 65 Years) 70% of older patients were in pain Nurses had limited awareness of their patients’ pain Documentation of pain assessment and management was lacking Pain was under treated
Coker et al, 2008
Hip Fracture Surgery In a study of 411 older adults (average age 82 years) hospitalized with surgery for hip fracture: –Pain reports postop of moderate-severe –Pain increased length of stay –Pain increased risk of delirium –Pain led to missed/shortened PT sessions
Hip Fracture Surgery (cont’d) Pain led to delayed ambulation after surgery Pain led to impaired locomotion 6 months after surgery
Morrison et al, 2003
“The clinician must accept the patient’s report of pain”
Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain American Pain Society, 2008
Assessment The Joint Commission (TJC) mandates routine pain assessment, treatment, and appropriate referral Quality Improvement studies in the literature report only mild success at increasing pain assessment
Joint Commission, 1997
AHCPR Acute Pain Management in Adults: Procedures
Observations of behavior and vital signs should NOT be used instead of self-report
AHCPR, p 4., 1992
Assessment
Self-report is the single most reliable indicator of pain
Pasero & McCaffery, 2011
Copyright, M. McCaffery, 1996.
Order of Assessment Indicators Self-Report Presence of pathologic condition or procedure that usually produces pain (APP) Pain behaviors –crying –grimacing –restlessness –guarding Pasero & McCaffery, 2011
Pain Management Drug treatment is the mainstay in the management of acute pain The use of analgesics singly or in combination that provide the greatest pain relief with the fewest adverse effects for each individual patient
APS, 2008
Four Principles of Pain Control 1. Give medications orally 2. Give medications regularly 3. Give medications in adequate dose 4. Give medications in combination
Oral Route Preferred for Managing all Types of Pain well-tolerated convenient least expensive fewest side effects IV route primary route in early post-op course
What Is The Best Schedule?
Around the clock
Pharmacological Treatment Non-opioid analgesics for mild to moderate pain Opioid analgesics
Adjuvant drugs
for moderate to severe pain
Why Three Groups Of Analgesics? Different mechanisms of action –NSAIDs: site of injury –Opioids: brain and spinal cord –Adjuvants: enhance modulation TAD
Multimodal or balanced analgesia; combine analgesics from different groups
Multimodal Analgesia Analgesics that work on different mechanisms along the pain pathway They produce a synergistic or additive effect Provides analgesia continuously, not PRN Pain relief usually occurs with lower doses of each medication This leads to fewer adverse effects of the analgesics Pasero, 2011
ASA Task Force The American Society of Anesthesiologists acute pain management practice guidelines state that clinicians should use multimodal analgesia whenever possible in the perioperative setting
ASA Task Force, 2012
Non-opioid Analgesics Acetaminophen, NSAIDs, Cox-2 drugs Ceiling on analgesia, but is individual Response to NSAIDs varies; if one is ineffective, try another Combinations: do not give more than one NSAID Acetaminophen + NSAID + opioid Okay if not contraindicated May give all at the same time Pasero & McCaffery, 2011
Acetaminophen Thought to work in the central nervous system Can be given orally, rectally, and IV Healthy adults not to exceed 4000mg per day Lower doses recommended for dehydrated, malnourished, elderly, or those who consume alcohol www.knowyourdose.org Acetaminophen Awareness Coalition
IV Acetaminophen “The efficacy of IV acetaminophen for the management of postoperative pain in adult patients has been studied in several randomized placebo-controlled trials around the world demonstrating effective pain relief and opioid dosesparing effects�
Pasero & Stannard, p. 114, 2012
IV Acetaminophen (Ofirmev) Adult postoperative patients 1000 mg IVPB every 6 hours for 24 to 48 hours Make sure patient is not receiving any other products with acetaminophen in it Vent piggyback tubing due to glass jar
Cadence Pharmaceuticals, 2010
NSAIDs Nonselective Inhibit both COX-1 and COX-2 Inhibiting COX-2 produces analgesia and anti inflammatory effects Inhibiting COX-1 causes adverse effects like GI bleeding and platelet dysfunction
Selective Inhibit just COX-2 Produce analgesia and antiinflammatory effects Only one available in US is celecoxib
Pasero & McCaffery, 2011
Parenteral NSAIDs Ketorolac slow IV push 15-30mg q 6 hours around the clock –do not give longer than 5 days –if creatine clearance less than 30, give 15mg
Ibuprofen 400-800mg IVPB 30 minutes q 6 hours around the clock Pasero & McCaffery, 2011
Preemptive Analgesia Dosing before painful experiences Decreases pain by timing medication’s peak effect with anticipated onset of pain Used with success with many orthopedic a surgeries and other surgeries with risk of developing persistent pain ( thoracotomy, mastectomy, amputation) Oxycodone, Gabapentin, Pregabalin Dahl, 2004
Anticonvulsants Decrease dose of opioid (dose-sparing) Improve pain control Preoperative Gabapentin (300-1200mg) decreases postop pain intensity and opioid consumption Prevent persistent postop pain syndromes Gabapentin or Pregabalin
Pasero, 2011
Opioids Morphine, Hydromorphone, Fentanyl Do not break, crush, or chew sustained-relief opioids Most short-acting opioids are similar PO-peak 1 hour, duration 3-4 hours IV-peak 15 minutes, duration 1-2 hours
PCA Definitions Patient Controlled Analgesia: Opioid delivered parenterally via a computerized pump that can be programmed to deliver medication in various ways Demand bolus dose: Opioid administered when the patient activates the pump by pressing the button Basal infusion: Opioid is administered continuously
PCA Opioids Morphine 1mg/ml Hydromorphone 0.2mg/ml Fentanyl 10-20 mcg/ml
PCA: Advantages Adjusts for individual variation in kinetics and dynamics Gives a sense of control Avoids bargaining and begging Safe and effective
PCA: Disadvantages Expense and availability of pumps Patient selection: anyone can push the button Push the button or suffer Not a panacea: opioid side effects persist The patient may not report pain that is not completely relieved
Patient Selection Able to push button Able to quantify pain Unable to tolerate oral analgesics Understand the relationship between pushing the button and medication delivery Understand the safety mechanisms of the machine Report unsatisfactory pain relief
Authorized Agent-Controlled Analgesia (AACA) Patient is unable to push PCA button Primary nurse or one family member is authorized to be the primary pain manager and has the responsibility of pressing the PCA button Written instructions provided and AA demonstrates understanding of the educational content Pasero & McCaffery, 2011
Epidural Analgesia
Epidural: Advantages Good to excellent analgesia with less side effects than with the use of systemic opioids – infrequent nausea – minimal sedation – earlier ambulation – retention of cough reflex – decreased pulmonary dysfunction – Decreased neuroendocrine and metabolic response to surgical stress
Safe and effective
Epidural: Disadvantages Expense and availability of pumps Infrequent use has led to misconceptions and fear with use Noninvasive monitoring required Rare, but serious potential complications
Epidural: Patient Selection Open heart surgery Abdominal procedures Anal or urogenital procedures Orthopedic surgeries of the lower limbs Thoracic surgeries Cancer pain Pancreatitis Complex regional pain syndrome, type I
Epidural: Contraindications Vertebral anomalies that would make catheter placement difficult Coagulopathies that may make the patient at an increased risk for epidural hematomas Systemic infections
Lipophilic Opioids Absorption rate is related to the lipid solubility of the medications Fentanyl –quick onset (5 minutes) –short duration of analgesia ( 2 hours) –smaller area of spread
Hydrophilic Opioids Provide analgesia over a greater area Requires close monitoring to detect rising dermatome levels that may lead to late respiratory compromise Onset of action – Morphine 30-90 minutes – Hydromorphone 15-30 minutes
Duration of analgesia – 18-24 hours
Opioid Side Effects Nausea Pruritus Constipation Sedation Respiratory Depression Urinary Retention
Local Anesthetics Work synergistically with opioids Dose sparing Block sodium channels and inhibit pain transmission Not reversed by Naloxone
Pasero & McCaffery, 2011
Local Anesthetic Side Effects Urinary Retention Hypotension Motor Blockade Systemic Toxicity –Tinnitus –Metallic taste –Tremors, seizures
Patient Assessment Pain –assessed and documented routinely –Report pain immediately • change in infusion/rate • alternative therapy must be considered
HR & BP should be assessed and documented routinely Assess and document the dressing and site appearance at least once a shift
Patient Assessment (cont’d) Sedation and RR should be assessed and documented frequently –sedation is the first sign of respiratory depression –increasing sedation may indicate a rising dermatome (sensory block) level –RR declines after the patient is somnolent, but before a decrease in oxygen saturation
Patient Assessment (cont’d) Assess Dermatome level (level of sensory blockade) with a cold stimulus routinely & PRN –only necessary when a local anesthetic is in the epidural solution –patients who can not report pain will also be unable to report a sensory block
RN Monitoring Use protocols and standing orders Assess sedation levels and respiratory status q 1 hour x12, q 2 hours x12, and then q 4 hours Remember, sedation always precedes respiratory depression Pasero & McCaffery, 2011
POSS Sedation Scale S = Sleeping, easily aroused 1 = Awake and Alert 2 = Slightly drowsy, easily aroused 3 = Frequently drowsy, arousable, drifts to sleep during conversation 4 = Somnolent, minimal or no response to stimuli Pasero & McCaffery, 2011
Naloxone Shallow, poor quality respirations Patient difficult to arouse Stop opioid Dilute naloxone with normal saline to 0.4mg/10ml or 0.04mg/ml Give 0.1-0.2mg Repeat q 1-5 minutes until respirations improve
Naloxone (cont’d) Opioid effect may outlast naloxone Giving too much can cause pain, hypertension, tachycardia, ventricular arrhythmias, pulmonary edema, and cardiac arrest
Pasero & McCaffery, 2011
ASPMN Guidelines on Monitoring for OpioidInduced Sedation and Respiratory Depression Nurses should advocate for opioid-sparing pain management strategies before, during, and after surgery
Jarzyna et al, 2011
Call For help! RRT Pain (greater than 3 on 0-5 or 6 on 0-10 Deterioration of motor function Increasing sedation or rising sensory block – this will occur prior to respiratory arrest – stop epidural infusion while contacting the anesthesiologist
Redness, swelling, pain or leaking at catheter site
Decreasing respiratory rate (<10) or oxygen saturation (<92%) Check RR full minute Fever Disconnection or break of epidural catheter
Continuous Peripheral Nerve Blocks Catheter inserted in OR with a continuous infusion of LA for the first 24-72 hours postop Disposable pump Hip, knee, shoulder, abdominal surgeries eg, On Q Pump
Pasero et al, 2007
Avoid Outdated Practices And Use Best Practices! No IMs! No PRN! (Patient may not ask) No Meperidine! (neurotoxicity) No single use of opioids
Potentiators Beware of “potentiators” Most are ”additives” Phenothiazines such as Phenergan are not potentiators. In fact, these drugs may actually counteract the effect of the opioid and cause increased intensity of pain. They also lower seizure threshold APS, 2008
Our Primary Goal Ensure high quality and safe care by balancing aggressive pain management with the prevention or minimization of adverse effects
Pain Organizations American Society of Pain Management Nurses 913-752-4975 aspmn@goAMP.com www.aspmn.org
American Pain Society 4700 W. Lake Avenue Glenview, Il 60025 847-375-4715 www.ampainsoc.org
Thank You For Your Attention! Questions?
References 1. Agency for Health Care Policy and Research (AHCPR) (1992). Acute pain management: Operative or medical procedures and trauma clinical practice guideline. (Publication No. 92-0032). Rockville, MD. 2. American Pain Society (APS) (2008). Principles of analgesic use in the treatment of acute pain and cancer pain, (6th ed.) Glenview, IL: APS 3.American Society of Anesthesiologists Task Force on Acute Pain Management (2012). Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management, Anesthesiology, 116 (2), 248-273. 4.Apfelbaum, J. L, Chen, C., Mehta, S. S., & Gan, T.J. (2003). Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia and Analgesia, 97 (2), 534-540.
References 5. Cadence Pharmaceuticals (2010). Ofirmev (acetaminophen injection) injection. [package insert]. San Diego, CA: Cadence Pharmaceuticals. 6. Coley, K. C., Williams, B. A., DaPos, S. V., Chen, C., & Smith, R. B. (2002). Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. Journal of Clinical Anesthesia, 14 (5), 349-353. 7. Coker, E., Papaioannou, A., Turpie, I., et al, (2008). Pain management practices with older adults on acute medical units. Perspectives (Gerontological Nursing Association (Canada)). 32, (1), 5-12. 8. Dahl, J. B., & Moiniche, S. (2004). Pre-emptive analgesia. British Medical Bulletin, 71 (1), 13-27
References 9. Dunwoody, C. J., Krenzischek, D. A., Pasero, C., Rathmell, J. P., & Polomano, R. C. (2008). Assessment, physiologic monitoring and consequences of inadequately treated acute pain. Pain Management Nursing. 9 (Suppl 1): 11-21. 10. Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J.S., Nisbet, A., Oakes, L., Dempsey, S. J., Santangelo, D., & Polomano, R. C. (2011). American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing, 12 (3), 118-145. 11. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2001). JCAHO pain standards for 2001. Retrieved June 1, 2003, from http://www.jcaho.org 12. Joint Commission on Accreditation of Healthcare Organizations. (1994). Accreditation manual for hospitals. Oakbrook Terrace, Il: The Joint Commission.
References 13. McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Studentsâ&#x20AC;&#x2122; Store. 14. Morrison, R. S., Magaziner, J., McLaughlin, M. A., Orosz, G., Silberzweig, S. B., Koval, K. J., & Siu, A.L. (2003). The impact of post-operative pain on outcomes following hip fracture. Pain, 103 (3), 303-311. 15. Pasero, C., & McCaffery, M. (Eds.) (2010). Pain assessment and pharmacologic management. St. Louis: Mosby Elsevier. 16. Pasero, C. (2011). Persistent post-surgical and post-trauma pain. Journal of PeriAnesthesia Nursing, 26 (1), 38-41.
References 17. Pasero, C., & Portenoy, R. K. (2011). Neurophysiology of pain and analgesia and the pathophysiology of neuropathic pain. In C. Pasero, & M. McCaffery (Eds.), Pain assessment and pharmacologic management (pp 1-12). St. Louis: Mosby Elsevier. 18. Pasero, C., & Stannard, D. (2012). The Role of Intravenous Acetaminophen in Acute Pain Management: A Case-Illustrated Review. Pain Management Nursing, 13, (2), 107-124. 19. Pasero, C., Eksterowicz, N., Primeau, M. et al. (2007). American Society for Pain Management Nursing position statement: Registered nurse management and monitoring of analgesia by catheter techniques. Pain Management Nursing, 8 (2), 4854.
References 20. St. Marie, B. (ed.) (2010). Core Curriculum for pain management nursing (2nd ed.) Kendall Hunt Professional. 21. Wu, C. L., & Raja, S. N. (2011). Treatment of acute post-operative pain. The Lancet, 377 (9784), 2215-2225.